HCV Infection in Marginalized
Populations
Brian Conway, MD, FRCPC
Vancouver Infectious Diseases Centre
(VIDC)
IDUs will drive the future HCV epidemic in
Canada
 300,000 HCV-infected Canadians,
including over 180,000 IDUs (60% of
prevalent cases)
 14,000 new cases are diagnosed each
year, including over 11,000 in IDUs
(78% of incident cases)
 Traditional medical models (diagnosistreatment-prognosis) will NOT apply to
their engagement in care and successful
implementation of successful antiviral
therapy
Remis, Health Canada, 2004. Fischer et al. Can J Pub Health, 2006. Zou. Can J Pub Health, 2003.
HCV Treatment Uptake Overall
Overall treatment uptake is low in most places…..
S. Mehta, with permission
Treatment Uptake in HIV-HCV Co-infection
N
Canada (Vancouver)
(Grebely et al. J Viral Hep 2008)
United States (Baltimore)
(Mehta et al. AIDS 2006)
Australia
(NCHECR 2005)
1,361
845
2,500
Cohort
HCV
Treatment
Uptake
Urban clinic of HCV &
HIV/HCV co-infected
patients
1.1%
Urban clinic of HIV/HCV
co-infected patients
3.4%
Needle exchange
4.0%
NCHECR, 2003. Australia.
Grebely et al. J Hepatology, 2006.
Barriers to HCV Treatment
Structural Barriers
•
•
•
•
Lack of infrastructure/multidisciplinary support
Segregated services
Provincial regulations
Cost
Provider Barriers
•
•
•
•
Poor awareness/education
Reticence to treat IDUs
Lack of providers, especially in remote
communities
Focus on HIV
Patient Barriers
•
•
•
•
•
Poor awareness/ education
Lack of symptoms
Competing health priorities (HIV, psychiatric)
Competing social priorities (housing, substance use,
financial)
Fear of side effects
Example: Overcoming structural barriers:
Integrated care / co-location of HCV & Substance abuse treatment
 Co-location of HCV care with
methadone maintenance has been
associated with favorable outcomes
(One-stop shopping)
 Integrated services for HCV, addiction,
mental health and psychosocial
problems
 Some programs Incorporate peer
educators
• Peer educators are patients who have
successfully completed HCV treatment
• Peers lead support groups with medical
providers
• Provide support through all stages
from HCV screening to treatment
Sylvestre 2007; Harris 2010; Litwin 2007; Edllin 2006; Grebely 2010. S. Mehta, with permission
Canadian situation
 2007 Canadian consensus guideline reads:
An
appropriately funded multidisciplinary effort is required to
improve care strategies for HCV infected IDU. Antiviral
therapy should be considered in selected patients in whom
HCV related morbidity & mortality will become relevant.
 BUT 80% of Canadian physicians specialized in treating
viral hepatitis would not treat active drug users
Myles et al. Can J Gastroenterology, 2011
Academic & Community Partnership Care
Model
 In the community
 Community & Academic Partnership
 ONE STOP SHOP
 Multidisciplinary
 Physicians (addiction & hepatology)
 Nurses
 Outreach workers
 Research assistants
 Culture of research & excellence
Patient Characteristics and Response Rates
 Mean age 43, 83% male, 55% genotype 2/3
 Early discontinuation - 11 patients (28%)
 Treatment-limiting adverse events – 5 patients (13%)
 nausea/vomiting, tinnitus, neutropenia, depression, anemia
 Illicit drug use – 6 patients (15%)
100
% Response
80
70%
55%
60
40
20
0
n=40
n=40
ETR
SVR
Grebely et al. J Gastroenterology and Hepatology, 2007.
Impact of Illicit Drug Use on Response
35% used illicit drugs in the last 6 months
48% used illicit drugs during treatment
10 (25%) used occasionally (monthly or once/twice)
9 (23%) used frequently (every day/every other day)
100
80%
80
64%
%SVR




60
57%
50%
53%
40
22%
20
0
n=26
n=14
>6 mos  6 mos
Drug Abstinence
n=21
n=19
n=10
n=9
None
Any
Occ
Freq
Illicit Drug Use
During Treatment
Grebely et al. J Gastroenterology and Hepatology, 2007.
Occurrence of Viremia in IDUs
 After adjusting for potential confounders:
 Individuals with viral clearance were 4 times less likely to develop infection
than those infected for the first time
 THESE DATA MAY NOT (OR MAY) APPLY TO TREATMENT-INDUCED
VIROLOGIC CLEARANCE
Grebely et al. Hepatology, 2006.
VIDC Baseline Characteristics
Characteristic
Total treatment cases, (n)
Median Age in yrs (Range)
Female, n (%)
HIV co-infection, n (%)
n (%)
302
53 (34-70)
44 (15)
43 (14)
HCV genotype, n (%)
Genotype 1
Genotype 2/3
189 (63)
113 (37)
Treatment experience, n (%)
Naïve
Experienced
252 (83)
50 (17)
Liver Cirrhosis, n (%)
33 (11)
History of recent IDU, n (%)
302 (100)
On methadone maintenance therapy, n (%)
211 (70)
Number of patients initiating treatment
N=302
SVR rates in all treated and evaluable
patients N=251
Treatment Discontinuation in all treated and
evaluable patients; n=251
Genotype 1
N=155
Genotype 2/3
N=96
Overall
N=251
Completed Therapy
95 (61%)
72 (75%)
167 (67%)
Discontinued due to:
60 (39%)
24 (25%)
84 (33%)
• Lack of Response
37 (24%)
7 (7%)
44 (17%)
• Drug Toxicity
13 (8%)
14 (15%)
27 (11%)
• Non-adherence / drug
relapse
10 (7%)
3 (3%)
13 (5%)
HCV Treatment Discontinuation Rates in
IDUs vs. non-IDUs
 Lee et al. (Liver Int. 1270-77, 2012)
 8853 courses of Peg-IFN-2a in non-IDUs
 68.3% completion rate
 10.3% discontinuation for toxicity
Conclusions
 HCV infection can be treated successfully in IDUs with
response rates and patterns of treatment discontinuation
similar to those seen in other populations, independent of
HIV co-infection status.
 As reflected in the 2012 Canadian guidelines for the
treatment of HCV infection, IDUs should be considered for
HCV therapy when this is medically indicated,
preferentially within the context of multidisciplinary
community-based models for the delivery of health care
where state-of-the-art expertise for the management of
HCV infection is available.
EnTEnTE
 Engage: Take people who are not involved in their own
health care and get them involved
 Test: Offer HCV testing in a setting favouring patient
engagement
 Engage: Once a test result is available, use it to establish a
long-term clinical relationship
 Treat: Optimize conditions to achieve SVR
 Engage: Towards a long-term solution to social inequality
THE (NEAR) FUTURE
 Test all marginalized populations for the presence of HCV
infection
 Select “optimal” patients for HCV treatment NOW
 Continue to engage non-treated patients in ongoing
models of care
 Seek & Treat models MUST be developed for HCV, with a
realistic expectation of disease eradication in selected
communities, given the increasing efficacy of available
treatment modalities